The Dark Heart of Global Health?

Guest post by Johanna Crane, a medical anthropologist and assistant professor at the University of Washington and author of “Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science.”

Global poverty isn’t just a tragedy. For the biomedical research community, it’s also an opportunity.

Last week, two of my students approached me wanting advice about how to get experience “doing” global health. This happens to me all the time. I teach classes on bioethics, science and society, the history of AIDS, and medicine across cultures.

Many of my students want to become doctors. Some of them care deeply about global health inequalities, while others are primarily concerned with how to get accepted to medical school. Either way, they’re already figuring out what so many North American universities have figured out in the last decade:

Global health is a hot commodity. That is both good and bad news.

I began working in HIV research in the late 1990s, shortly after the first effective HIV medicines transformed the disease in the U.S. and people with AIDS stopped dying, and starting living. I lived in San Francisco at the time, and I remember the week in 1998 when the Bay Area Reporter, the local gay newspaper, celebrated the fact that they had received no death notices for the first time since the epidemic began in 1981.

To folks who had come of age during the AIDS era, it seemed like nothing short of a miracle. Unfortunately, it would take nearly a decade before the hardest-hit parts of the world, mostly in Africa, would see much benefit from this discovery.

Back then, Americans weren’t scrambling to go to Africa and “do” global health the way they are now. Rather, African countries were ignorantly written off as places where people “didn’t understand Western time” and wouldn’t take the drugs properly – a view backed by the multinational pharmaceutical industry because it let them off the hook for pricing their products too high for poor countries.

And despite really important early studies done by African researchers in Congo, Uganda, and elsewhere, AIDS science was seen as something that happened in the U.S. and Europe, not Africa.

Today, the landscape of AIDS research is dramatically different. As I describe in my new book, Scrambling for Africa, African countries such as Uganda that were once ignored by all but a handful of American researchers have now become sought-after “partners” by some of the most prestigious research universities in the world.

Why? Because over the last decade there has been an explosion of interest and investment in “global health” in this country, and when Americans—like my students—say they want to “do” global health, what they usually mean is that they want to go to Africa.

The benefit of this transformation is the fact that Western funders (the U.S. in particular) stopped stonewalling and began funding HIV treatment in poor countries. This actually happened a decade ago, when then-President George W. Bush announced his $15 billion PEPFAR program back in 2003.

While it may pain liberals to admit this, it was Bush who actually took the bold step of putting big money behind HIV treatment in Africa. Bill Clinton, on the other hand, sided with the pharmaceutical companies for much of his administration.

Around the same time, American HIV researchers started looking for ways to help curb the epidemic in less wealthy parts of the world. Many of them turned towards English-speaking countries in sub-Saharan Africa, where the epidemic had hit hardest and a common language smoothed efforts to collaborate.

The fact that HIV treatment was coming to the continent made it a more attractive place to do research. The large numbers of untreated and newly-treated patients represented a research population that was simply unavailable in the U.S.

As one American HIV researcher who shifted his work to Uganda told me, Africa had become “in vogue.” As time passed, what started as an interest in HIV expanded to include other infectious diseases, especially malaria and tuberculosis, and, more recently, “non-communicable diseases” or “NCDs” like cancer.

This shift has brought a great deal of resources to some African clinics and hospitals. For example, my book describes the transformation of one Ugandan HIV clinic from a two-room facility run out of a donated shipping container into a multi-building, state-of-the-art HIV treatment and international research center. One Ugandan researcher explained it to me like this:

“HIV,” he said, “opened Uganda’s doors to a lot of international organizations.” AIDS, he went on, “is a bad thing that happened to Uganda, but it has also exposed the country to certain things maybe we would never have seen.”

So what’s bad here? Why would anyone want to criticize this outpouring of attention and funding to health care and health research in poor countries? In part, for exactly that reason – because it seems beyond criticism, and that should make us nervous.

In some ways, these efforts bring helpful resources to underfunded health care systems, but at the same time they generate a “scramble” for desirable—read: poor—research and clinical sites where Americans can go to “do” global health. In short, global health needs inequality, even values it, in a way that deeply troubles the field’s defining goal of redressing global health disparities. This is the potential “dark heart” that global health would rather not confront.

In an effort to promote collaboration and avoid appearances of parasitism, American institutions often use the language of “partnership” to describe their relationships with African clinics and universities. The promotion of collaboration is all well and good, but too often global health boosters overlook they ways in which these programs are designed by and for American, not African, faculty and students. American research money funds studies designed by American researchers; African researchers are often brought in after the fact to facilitate ethical approval and patient recruitment.

In Uganda, many aspiring health researchers must fund their studies out of their own pockets; it is only if they become “attached to someone” (as one Ugandan physician told me) that they might acquire foreign funding, and then only if their research question is of interest to the international funder.

Doctors at Donka

Moreover, despite the language of “partnership,” American global health programs tend to set up their own, independent funding streams in Africa—often through “shell” NGOs—rather than work with existing administrative infrastructures, which are seen as “too difficult.” Difficult they may be, but that is also a convenient excuse for keeping the purse strings tightly in American hands.

At the Ugandan clinic I studied, international funding has introduced new inequalities in employment as doctors and health care workers with American-backed paychecks often make much more than those working on government health salaries. One clinic doctor I interviewed put it quite bluntly when he told me, “HIV money and research money has somehow killed our health system.”

As one Ugandan researcher I spoke with put it, “We have loads and loads of patients. Other people don’t have patients. They are training doctors under video – I saw it in Norway. They have never touched patients!” As a recent article in the Chronicle of Higher Ed noted, this desire and opportunity to “touch” patients is deeply troubling when it comes to untrained American undergraduate students (such as the ones who often approach me in search of programs that will allow them to do just that).

So, what do I tell the students who come to me looking for advice about getting into global health? I affirm their desire to fight poverty and inequality, but I also ask them to consider the ethics of global health exchanges. Sometimes tell them things they don’t want to hear:

Going to Africa is going to primarily benefit you, not African patients.

People in Africa do not need you to educate them about HIV.

You are more likely to burden, rather than help, local health care providers.

Ultimately, the problem isn’t with these individual students, or with well-meaning global health researchers. The problem is that very few people are willing to challenge the heroic narrative of global health and the “white savior complex” that puts good intentions beyond reproach. This narrative obscures the ways in which global health needs and seeks out global poverty, even in its efforts to redress it. Instead, it allows us to bask in a sentimentalism that lets us pat ourselves on the back for simultaneously cultivating global citizens and fighting health inequalities.

This is especially evident in Seattle, where global health is a full-fledged “sector” of our economy, and an increasing motivator of local technological entrepreneurship. In this heroic narrative, U.S. global health efforts are framed as humanitarian and altruistic, even when they benefit American careers first and foremost.

Johanna Crane

Johanna Crane is an assistant professor at the University of Washington-Bothell in Interdisciplinary Arts and Sciences. A medical anthropologist, Crane teaches a variety of courses on the complex workings of power in relation to medicine, science, and technology. Her book Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science (Cornell University Press, 2013) is based on Crane’s fieldwork conducted in the U.S. and Uganda focused on how much of Africa has moved from being largely excluded from medical advances to becoming a key locus of knowledge production in global health and HIV research.

I find it a bit disheartening that this piece, that actually provides some good points for consideration, is so unbalanced and obviously biased. It would have been a better read and more informative with both the pros and cons discussed, or with some suggestions for better managing and integrating research/globally funded projects for health system strengthening. While there are valid questions raised about unintended consequences of donor driven agendas and the creation of vertical specialty programs in SSA, not all global health programs are created equally. There is, in fact, some research being done with African partner sites sharing equal responsibility for the projects (including the needs assessment). And, I think it is short-sighted to overlook the knowledge exchange that is taking place in many programs. I completed my degree in a program that had mostly students from low and middle income countries (out of 18 MS students, 2 from US, 1 from Finland all others from LMICs) who had come to build their own public health knowledge and skills to return to their countries and help drive the research/health agendas toward health system strenthening.

http://humanosphere.kplu.org Tom Paulson

Hi Amy, I think the benefits of global health research have been more than adequately represented in, well, most stories about global health. The point of Johanna’s piece (and her book) is to bring attention to a much-less appreciated or discussed potential problem – the potential for (likely unintended, in most cases) exploitation of the poor when we do studies in the developing world. While there may be an increasing number of true partnerships in health research done in poor communities, I suspect they are the exception rather than the rule. Cheers

Johanna Crane

Hi Amy, Thanks for your comment. I agree that not all global health programs are equal, and there certainly are examples of programs that take issues of equity very seriously — it sounds like your program may have been one of them. But I also think that many programs assume that good intentions alone are enough, and do not critically evaluate the ways in which their programs prioritize the needs of Americans over those of partners.

Judy Anderson

Hi, I agree with Johanna. When I was working with HEAL Africa, we were very careful about selecting partners for research, after a few disastrous experiences. Too often people want to come and “help”, when there are people locally who are more trained. There is definitely a benefit to working cross-culturally, but it should be both ways. If someone goes to a hospital in Africa, someone from that hospital should come to the US…or something like that. Our concern was that the Congolese doctors be part of designing the research subject from the beginning, and be part of the” glory”–presenting & listed on the papers. So that’s what happened. Money has so much power that too often people with resources (like patients) that aren’t valued as much as cash– don’t have the opportunity to say “no” or define the relationship. Or are put in the position where they don’t realize that they have a chance to have input!

TheTracker

The reasoning here is painfully circular. To help the poor, logically there must be poor people. To help the sick, you “depend upon” the existence of sick people. Is that problematic? No, not really, unless you think that the existence of a restaurant somehow causes people to be hungry.

And then there’s another very obvious point which does not add anything to our understanding: “Many people are partly or entirely selfish in how they go about things, even things intended to help others!” And that truism would imply what, exactly? Undertake efforts to make the world better only if you are amply provided with morally perfect, entirely ego-less individuals to carry out said good works?

I do not appreciate, from reading this article, the sophisticated understanding of power relationships in medicine which the author is said to possess. She fails to consider any valid reasons why these project might want to maintain a degree of control over the resources they provide — such as the government corruption which is endemic in many African nations. There is no concrete plan of action suggested, the author seemingly content to assume a general attitude of moral superiority over the people doing the actual work.

Johanna Crane

Dear Tracker, You are correct that this piece is mainly a critique, and does not suggest a concrete plan of action. I do address that issue throughout my book, however. I don’t mean to assume a tone of moral superiority. In the book, I state clearly that all the critiques I make of global health can (and should) be applied to myself as well. But I disagree with your assertion that my logic is circular. My point is not that helping the poor requires poor people, but rather that many things other than helping the poor are done in the name of global health. Some of these things have very little to do with helping the poor (and in fact, even work against this goal).

TheTracker

“many things other than helping the poor are done in the name of global health. Some of these things have very little to do with helping the poor (and in fact, even work against this goal).”

That’s a fair point. I suppose if one has a completely idealistic and uncritical attitude towards global health, your article could be a good introduction to the moral complexities of wealthy white people plunging into the midst of problems they don’t understand. I suppose I start from a more cynical place in thinking that, like most human enterprises, global health will be performed out of a mix of selfish and selfless motives, and sometimes successful and sometimes counterproductive.

It’s interesting that you bring up the issue of sick people as a “resource” which semi- or untrained caregivers exploit to further their education. That’s true but, as I’m sure you know, is not limited to global health, but is the basis of the entire system of clinical medical education and residency. Good pathology — good experience — is a resource. And it is a necessary (and sadly, renewable) resource out of which we build competent doctors and nurses.

The book’s transparent lack of solutions is probably the most painful part about the book to read. For example, there is a ton of material about how the African researchers are not treated as equals etc but there is not a lot of critical analysis into the root causes and potential solutions. If you have a research project that generates a ton of data, and African scientists are invited to publish, and NO ONE takes you up on the offer, then whose fault is that? When you up the ante by offering first authorship and time intensive mentoring — you still hear crickets. (At least that is my N=1 experience.)

I am of the opinion that this miserable state of affairs may be due in part to lack of talent, but I also think that it is in large part structural — at many African universities there are simply no incentives to publish. Your advancement depends on seniority, teaching, etc but not your contributions to science. There are clear incentives for African researchers to become co-PI’s (i.e., they get written into an NIH grant for “10% effort”, but because the university has NO SUCH THING as effort reporting then this basically amounts to a boost in salary which is of course highly welcome if you are getting paid $6000 a year as a medicine faculty member) but no incentives to publish (the U.S. researchers only want a Ugandan PI for access to patients and/or window dressing for the NIH, doesn’t matter if they publish or not; and as I described above there are no incentives to publish from the perspective of advancement at the university).

These and other critical details are rather lost in the book, and the tone that is adopted only makes these omissions more apparently. I agree with TheTracker that it is basically an opportunity for the author to assume an attitude of moral superiority over the people doing the work.

Feven Berhane

Seriously, THANK YOU SOOO MUCH! Opened my eyes you did!

Mrs Marian

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Humanosphere

Seattle is the epicenter of a global effort to beat back poverty and illness in the poorest corners of the world. We'd like Humanosphere to be your go-to source for news, conversation and analysis about this effort as it unfolds. Your host is Tom Paulson, a reporter with decades of experience covering science, medicine and global health in the US and beyond.